A few months ago, I went to the doctor for a routine appointment that involved some lab work. The doctor was in-network, the copay was $25, and the visit was quick. Which is why when I received a bill in the mail months later asking me to pay up, I had trouble remembering what it was even for. It turned out the lab work was not covered—even though on past visits it had been.
It wasn’t the first time I had received an unexpected medical bill for something I thought was covered by my insurance, nor will it likely be the last. I bring up the episode not because it was unusual, but precisely because it is not. The experience of receiving a surprise—or surprisingly high—medical bill is something that many Americans using our convoluted private health insurance system are familiar with.
Almost everyone I know who has health insurance has had the experience of receiving such a bill. What follows after that, should you decide to forge ahead and dispute it, is a daisy chain of phone calls to the insurer and/or the provider, spread out over weeks, even months—hours of your life spent wrangling over a bill that you never even should have gotten. Sometimes the case is resolved; other times you just give up and send the check. In every case, the patient is overmatched, dwarfed by our complex, gargantuan health-care bureaucracy.
The act of disputing a medical bill is as maddening as dealing with the local cable or telephone company. Except in this instance, you’re dealing with an industry that’s in the business of something more important: your life. And the prevalence of the experience is a testament to the absurd complexity and enduring mediocrity of our health system.
To dive into the world of medical billing is to find yourself in a Kafkaesque landscape of opaque bureaucratese, slack-jawed service, and shameless profiteering. The stories defy belief—and there are a lot of them.
There’s the woman who gave birth to a baby in an in-network hospital with an in-network doctor—but was later billed because a second pediatrician had been called in to assist during delivery, a doctor who was out-of-network. The woman told Modern Healthcare, “I was in absolutely no condition to be refusing care or making sure someone was in-network at the time.” (Excuses, excuses.)
There’s the breast cancer patient who went to an in-network doctor for reconstructive surgery but was then billed $10,000. The reason: Only one of the doctor’s two offices participated in her health plan, and she chose the wrong one.
There’s the young woman, an acquaintance of mine, who had to be taken by ambulance to the emergency room because of an allergic reaction. Months later, she received a bill for hundreds of dollars from the ambulance company. Even though she had insurance and went to an in-network hospital, she had ridden in an out-of-network ambulance.
There is a name for this practice: balance billing. It’s when a doctor or other medical service provider—a lab, an ambulance—bills a patient directly for a portion or the entirety of a bill that the insurer won’t pay. The most common examples of balance billing involve patients being treated—unwittingly, in most cases—by an out-of-network provider and then getting billed for it afterward. For instance, it’s not uncommon for hospitals to outsource medical services like radiology and anesthesia to doctors who don’t participate in the same health plans as the hospitals. These providers in turn go directly to the patient to collect their fee.
Numbers are hard to come by, but some research has illustrated the extent of the problem. According to one study by Kelly Kyanko of New York University School of Medicine (the pregnant woman in that anecdote above!), 40 percent of respondents in a survey reported receiving out-of-network health care involuntarily or unexpectedly. A 2008 report in Bloomberg News stated, “Economists and patient advocates estimate that consumers pay $1 billion or more a year for which they’re not responsible.” The high price tag is no surprise—out-of-network bills are notoriously exorbitant. To take one example, Medicare pays providers $405 for an MRI of the brain; an out-of-network provider charges an average of $2,929 for the same procedure. A study last year by America’s Health Insurance Plans, the insurers’ industry group, found that out-of-network charges for certain procedures were on average 300 percent more expensive than the Medicare rate.
What does federal law have to say about this? Not much. Medicare bans balance billing of beneficiaries by providers that accept Medicare, but that’s pretty much it. The Affordable Care Act requires insurers to pay out-of-network providers the same amount they would pay in-network providers in the event of medical emergencies, but there is nothing in the law that prohibits balance billing—in other words, the out-of-network provider can still come back and charge you for additional costs beyond what your insurer paid.
At the state level, there is the usual confusing collage of protections and loopholes. Most states have laws on the books against balance billing by in-network providers; this means that the doctor who takes your insurance but chafes at the low rates paid by the insurer can’t bypass the insurer and go directly to you to collect a few extra dollars. Some states have taken steps against out-of-network balance billing—that’s when an out-of-network doctor bills you directly for something you thought was covered by your insurance. The most stringent law is New York’s, which took effect last April. That measure protects patients from being charged for out-of-network services that they did not consent to ahead of time. If the patient does receive a surprise bill, the state has set up an independent dispute-resolution process between providers and insurers to settle on a fee, leaving patients free and clear of any costs beyond their in-network obligations (copays, deductibles).
But the problem of bad bills goes beyond balance billing. The fact is, an insured consumer who avails herself of her coverage should be prepared to wade into a morass of inefficient and error-ridden bureaucracy. Mistakes are made, often (the passive voice is intentional; no one ever commits these mistakes—they just happen). Pat Palmer, founder of Medical Billing Advocates of America, a patient advocacy firm, contends that up to 80 percent of medical bills contain errors. (Palmer’s work on behalf of patients was featured in Steven Brill’s blockbuster 2013 Time article, “Bitter Pill: Why Medical Bills Are Killing Us.”)
More than once, I’ve received a bill that was sent “by mistake.” Only after several phone calls with the provider was the mistake—if it was that—acknowledged and the bill scratched from my record. My acquaintance who was sent a bill by the ambulance company challenged her bill too. After more than six months, and many hours on the phone with half a dozen people, she finally spoke to a representative who said that the insurance company should have paid for it months ago, and she made the charge disappear, just like that. It’s enough to make you wonder: Is counting on consumer exasperation—the patient waving the signed check of surrender—part of the business plan?
That Brill piece, now rightly considered a classic, certainly makes one think so. For that story, Brill dug deep into the practice of overcharging at hospitals. He detailed flagrant instances of hospitals slapping unreasonable price tags on goods and services they provided ($7 for one alcohol swab, when a box of 200 goes for $1.91 on Amazon), even double- and triple-billing for certain items (charging a general facilities fee in the thousands of dollars, then separately charging items that should have been included in that fee). To top it off, all these charges appear in an inscrutable bill that most people, especially ones recovering from hospital stays, can’t decipher. Some people just pay up; others can’t; a few go bankrupt.
The Internet is rife with advice on navigating the minefield of medical billing. The same tips keep popping up: Do your homework, make sure providers are included in your plan, review bills when you get them, be prepared to negotiate. There are also services, like Pat Palmer’s, that help consumers out by doing the heavy lifting of decoding invoices, haggling, and hectoring. And so it is that an insured person in the most advanced health-care system in the world settles his bills as if he were buying a rug in the kasbah.
Underpinning the sins of balance billing and egregious overcharging is the lopsided relationship that allows those sins to persist. The imbalance of power between health consumers on the one hand and the health-care industry on the other is a foundational flaw that afflicts our system. Set aside the fact that we get bad bills to begin with. All too often, when you spot something amiss on your bill, you’re on your own. The fact that an entire cottage industry of consumer assistance around the problem of health-care billing has emerged is both a telling indicator and an absurd development.
As New York’s new law suggests, states are not powerless. Already, there has been a push to increase transparency in health-care pricing the last few years, spearheaded by the Obama Administration. But transparency isn’t enough. States should be more proactive in solving the problem of balance billing. If you pay a copay and/or deductible for services that, to the best of your knowledge, are in-network, that should be the extent of your financial contribution. New York’s solution seems sensible: If a provider objects, solve the dispute via an independent process that leaves the consumer protected.
Other states have their own ideas. Colorado requires insurers to pay non-network providers what they charge—not discounted rates—when they provide services at in-network hospitals. Legislation being considered in California requires that out-of-network care options be provided at the same rate as in-network care when the number of in-network providers under a patient’s plan is insufficient.
Still, we need a solution beyond the patchwork of different state rules. Balance billing, overcharging, and the horrors of our health-care bureaucracy aren’t fully addressed by the ACA, President Obama’s landmark achievement. And if we recall Obama’s oft-stated rationale for the ACA—that no American should ever go bankrupt because of health bills—then the ACA has done an incomplete job. Today, it’s entirely possible for someone with insurance to get billed for tens of thousands of dollars by an out-of-network provider. The federal government should look at adopting some of the state regulations that have been most effective and promulgating them at the national level.
Even better, it should look to its own recent addition, the Consumer Financial Protection Bureau (CFPB), as a model for protecting health consumers. Among the CFPB’s most laudable accomplishments is its responsiveness at the retail level. Americans victimized by financial fraud now have a high-functioning and tech-savvy advocate to turn to when they need it. Patients staring at surprise—and, in many cases, sky-high—medical bills shouldn’t have to go into battle with providers and insurers alone. The government should see to it that they don’t.
I was one of the lucky ones. The surprise bill I got a few weeks ago wasn’t for too much money: $62. What did I do? Reader, I paid it. I could have challenged the charge, spent hours on the phone with the provider, and eventually negotiated it to nil. But with two young children and precious little time, I wrote it off as a levy I could swallow, part of the price of being insured in twenty-first-century America. In other words, the system worked.